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Date am 2/22/2018 10:56:25AP SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 2/22/2018 <br /> Record Selection Criteria: Facility ID FA0006300 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 SSN/Fed Tax ID <br /> Owner ID OW0017048 New OwnerJD : <br /> Owner Name l .� I.� C , <br /> Owner DBA <br /> owner Address 686 E LOCKEFORD AVE <br /> LODI, CA 95240 <br /> Home Phone_2,0 83_754 ^ <br /> Work/Business Phone .2,0 gg5gq 153Y)-07t)-7 <br /> Mailing Address -P&B@3E-2672, IOUD <br /> 40 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID ER 'D--FyX00 00 10182077 j <br /> Far i Name ON-EN6(p)FFR1{yG_ Q� <br /> o atiOn 86 E LOCKEFORD AVE t! <br /> LODI, CA 95240 ,�/ p \ <br /> one^Q� YlV 1( <br /> Mailing d ress -pe-.gQX_2672_ <br /> LODI, CA 95241-2672 <br /> Ca a of •E9Fay'son'€n9inearara9,- '� /� " Cad i <br /> L cation Code 02 - LODI \ /� Alt Phone <br /> BOS District 004-WINN, CHARLES Fax <br /> AIIPN 04905003 .6 EMail: <br /> EMERGENCY N IFICq.TION CONTACT INFORMAT '�u`,T <br /> Cont t Nlme <br /> 'tie <br /> Day Pho e <br /> Night Pho ie <br /> ACCOUNTS RECEIVABLE FI ION <br /> Account ID AR0007513 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name (Circle One) <br /> Account Balance as of 2/22/2018: $0.00 <br /> (Circle One) <br /> Transferto Active/Inactve <br /> Agram/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> PI-HMBP-Regular-Primary Location 0 PR0527524 EE0008709-JAMIE LIMA Active Y N A I D <br /> 2220-SM HW GEN<5 TONSNR PRO528798 EE9999998-ONE VACANT1 Active Y N A I D <br /> 2381 -UST FACILITY(BEFORE 1/84)-obsolete PRO504748 EE9999998-ONE VACANTt Inactive Y N A I D <br /> 2831 -AST FAC >/=1,320-<10 K GAL CUMULATIVE PRO528797 EE0000030-AARON HANG Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARGE PRO533944 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,and/or project specific,PHSi hourly charges associated with this facility <br /> or activity will be billed to the party identiFled as the OWNER on this form. I also certify that all operations will be performed in accordance with all applicable Ordinance Cedes and/or Standards and State ander <br /> Federal Laws, <br /> APPLICANT'S SIGNATURE: Date / / <br /> Program Records to be TRANSFERED: "$25.00= Amount Paid Date / / <br /> Water System to be TRANSFERED: Amount Paid Date I / <br /> Payment Type- Check Number Received by <br /> EHD Staff: Date / / Account out: Date / / <br /> COMMENTS: <br /> awrl <br /> Invoice#: <br /> �u� S a <br />